Junction Incompetence Research Articles

Randomized Clinical Trial of Endovenous Laser Ablation Versus Conventional Surgery for Small Saphenous Varicose Veins

No randomized clinical trial comparing treatment options for small saphenous vein (SSV) incompetence exists, and there is no clear evidence that this axis behaves the same as the great saphenous vein after treatment. This means that the existing literature base, centered on the treatment of great saphenous vein incompetence cannot simply be extrapolated to inform the management of SSV insufficiency. This trial compares the gold standard of conventional surgery and endovenous laser ablation (EVLA) in the management of SSV incompetence. Patients with unilateral, primary saphenopopliteal junction incompetence and SSV reflux were randomized equally into parallel groups receiving either surgery or EVLA. Patients were assessed at baseline and weeks 1, 6, 12, and 52. Outcomes included successful abolition of axial reflux on duplex, visual analog pain scores, recovery time, complication rates, Venous Clinical Severity Score, and quality of life profiling. A total of 106 patients were recruited and randomized to surgery (n = 53) or EVLA (n = 53). Abolition of SSV reflux was significantly higher after EVLA (96.2%) than surgery (71.7%) (P < 0.001). Postoperative pain was significantly lower after EVLA (P < 0.05), allowing an earlier return to work and normal function (P < 0.001). Minor sensory disturbance was significantly lower in the EVLA group (7.5%) than in surgery (26.4%) (P = 0.009). Both groups demonstrated similar improvements in Venous Clinical Severity Score and quality of life. EVLA produced the same clinical benefits as conventional surgery but was more effective in addressing the underlying pathophysiology and was associated with less periprocedural morbidity allowing a faster recovery. ( NCT00841178.).

Endovenous laser ablation of the great saphenous vein in patients with von Willebrand disease

Introduction. Patients with von Willebrand disease have a high risk of bleeding during the surgical treatment of varicose veins. Endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is a minimally invasive treatment for saphenofemoral junction incompetence. The number of complications and relapse rate of EVLA are lower than in those of conventional surgical treatment. Case presentation. A patient with great saphenous vein insufficiency, von Willebrand disease and hypofibrinogenemia successfully underwent endovenous laser ablation. Replacement therapy with cryoprecipitate was administered preoperatively and postoperatively. The surgical procedure and postoperative course were unremarkable. Conclusion. In patients with von Willebrand disease and other coagulation disorders, endovenous laser ablation is a safe and effective treatment. The use of minimally invasive treatment, the adequate correction of haemostasis, and close cooperation between the haematologist, anaesthesiologist and endovascular surgeon reduce the risk of bleeding.

Hemodynamic patterns of reflux in primary sapheno-popliteal junction incompetence

Duplex ultrasound investigation (DUI) has considerably improved the diagnosis of anatomical venous variations in the popliteal region: however, some pitfalls still remain concerning the hemodynamics of incompetent sapheno-popliteal junctions (SPJs). Aims of this study were to assess the prevalence rates of the hemodynamic patterns of reflux, either diastolic or systolic or both, in a large series of patients with SPJ incompetence, and to analyze the origin of the systolic components of the reflux. Four hundred and fiftythree patients, 83 males and 370 females, mean age 58.0 years&plusmn;SD 13.8 with primary SPJ incompetence (512 limbs) underwent preoperative DUI using the Paran&agrave; manoeuvre, a dynamic test able to develop systolic and diastolic pressure gradients through the reflex activation of muscle pumps. Of the 512 incompetent SPJs, 420 showed isolated diastolic reflux, 9 isolated systolic reflux and 83 systolic reflux followed by diastolic reflux. Altogether, 92 SPJs over 512 (18%) showed a systolic component of the reflux, which originated from the popliteal vein in 78 cases (15%) and from the gastrocnemius veins (GVs) in 14 cases (3%). In these latter cases, the short saphenous vein and one or more GVs showed a common trunk. Our findings show that the detection of a systolic component of the reflux in incompetent SPJs is not an uncommon event and suggest that treatment strategy should be differentiated according to the origin of the systolic reflux, given their different hemodynamic behavior.

Treatment of Reticular and Telangiectatic Leg Veins: Double-Blind, Prospective Comparative Trial of Polidocanol and Hypertonic Saline

Sixty-three subjects' legs were randomized to receive treatment with polidocanol (POL) or hypertonic saline (HS) for telangiectasias and reticular leg veins. To compare the safety and efficacy of two sclerosing agents in three dermatologic surgery practices. After exclusion of saphenofemoral junction incompetence, each subject's veins were categorized (telangiectasias <1 mm and reticular veins 1-3 mm) and randomized. Telangiectasias were treated with POL 0.5% or 11.7% HS and reticular veins with POL 1% or 23.4% HS. An independent, blinded physician determined efficacy and adverse events. Subject satisfaction questionnaires were administered and global clinical improvement assessments performed. All patients completed four visits at 0, 1, 4, and 12 weeks. Patients reported significantly greater pain during treatment with HS (2.42) than POL (1.03) (p < .001). There were no significant differences in physician-assessed improvement of reticular leg veins or telangiectasias; subject- or physician-assessed overall improvement; or physician-assessed phlebitis, pigmentation, edema, or matting in either of the three practices or the entire cohort. Two subjects developed ulcerations with HS. No ulcerations or allergic reactions developed after POL injections. Both agents provided effective treatment, but HS caused 2.35 times as much pain during injections and resulted in two episodes of tissue necrosis.

Endovenous Laser Ablation in the Treatment of Small Saphenous Varicose Veins

The study was performed to evaluate the clinical and technical efficacy of endovenous laser ablation (EVLA) of small saphenous varicosities, particularly in relation to the site of endovenous access. Totally 59 patients with unilateral saphenopopliteal junction incompetence and small saphenous vein reflux underwent EVLA (810 nm, 14 W diode laser) with ambulatory phlebectomies. Small saphenous vein access was gained at the lowest site of truncal reflux. Patients were divided into 2 groups: access gained above mid-calf (AMC, n = 33) and below mid-calf (BMC, n = 26) levels. Outcomes included Venous Clinical Severity Scores (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), patient satisfaction, complications, and recurrence rates. Both groups demonstrated significant improvement in VCSS, AVVQ, generic quality of life Short Form 36, and EuroQol scores (P < .05) up to 1 year. No differences were seen between AMC and BMC groups for complications (phlebitis: 2 [6%] and 1 [3.8%], P > .05; paresthesia: 2 [6%] and 5 [19%], P = .223) and recurrence (3 [9%] and 1 [3.8%], P = .623), respectively. The site of access in our study does not appear to influence complications specifically neural injury or recurrence rates.

Clinical and technical outcomes from a randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

This report describes the clinical effectiveness and recurrence rates from a randomized trial of endovenous laser ablation (EVLA) and surgery for varicose veins. Some 280 patients were randomized equally using sealed opaque envelopes to two parallel groups: surgery and EVLA. Inclusion criteria included symptomatic disease secondary to primary, unilateral, isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein (GSV). Outcomes were: technical success, recurrent varicose veins on clinical examination, patterns of reflux on duplex ultrasound examination, and the effect of recurrence on quality of life, assessed by the Aberdeen Varicose Vein Questionnaire (AVVQ). Assessments were at 1, 6, 12 and 52 weeks after the procedure. Initial technical success was greater following EVLA: 99.3 versus 92.4 per cent (P = 0.005). Surgical failures related mainly to an inability to strip the above-knee GSV. The clinical recurrence rate at 1 year was lower after EVLA: 4.0 versus 20.4 per cent (P < 0.001). The number of patients needed to treat with EVLA rather than surgery to avoid one recurrence at 1 year was 6.3 (95 per cent confidence interval 4.0 to 12.5). Twelve of 23 surgical recurrences were related to an incompetent below-knee GSV and ten to neovascularization. Of five recurrences after EVLA, two were related to neoreflux in the groin tributaries and one to recanalization. Clinical recurrence was associated with worse AVVQ scores (P < 0.001). EVLA treatment had lower rates of clinical recurrence than conventional surgery in the short term.

Junction jump sign: a useful adjunct to the precise positioning of the catheter tip during endovenous thermal ablation

Duplex ultrasound imaging plays a key role in the increasingly popular, minimally invasive endothermal treatment of varicose veins. Accurate placement of the echodense tip of endovenous catheter distal to the site of junctional incompetence is by far the most critical step in the entire thermo-ablative procedure. This is achieved technically by precise sonographic visualization of the junction and placement of the working tip of catheter distal to the junction. We wish to report an additional observation; the ‘junction jump sign’ where the tip of the catheter is observed to recoil towards the transducer as it traverses past the junction from the deep to the superficial venous system. This sign can be used as a useful adjunct to position with confidence the working tip, especially in situations where precise identification of the catheter tip is difficult.

The role of circumflex femoral veins in the saphenofemoral junction incompetence: a case report

A 31 year-old female patient, an opera singer, came for a consultation, mainly for aesthetic problems of the lower limbs. An asymptomatic bilateral P-point pelvic shunt was demonstrated by the EchoDoppler, while no nutcracker syndrome was detected. The examination demonstrated a medial circumflex femoral vein (MCFV), going into the common femoral vein and then into the great saphenous vein (GSV). The Valsalva manoeuvre showed the GSV terminal valve incompetence. A dilated MCFV vein at the level of the saphenofemoral junction was the source of the reflux through the GSV, while the external iliac vein was competent. GSV reflux with Valsalva was present only in the lying position. Flow in the MCFV was directed toward the CFV during and after the Valsalva. The examination shows clearly that a GSV reflux can sometimes occur in absence of iliac reflux. Circumflex femoral veins (medial and lateral) are anatomical variations, but common findings during ordinary EchoColourDoppler investigations of the venous system of the lower limbs.

Randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

Endovenous laser ablation (EVLA) is a popular minimally invasive treatment for varicose veins. Surgical treatment, featuring junctional ligation and inversion stripping, has shown excellent clinical and cost effectiveness. The clinical effectiveness of both treatments was compared within a randomized trial. Some 280 patients were randomized equally into groups receiving either surgery or EVLA. Participants had primary, symptomatic, unilateral venous insufficiency, with isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein. Outcomes included: quality of life (QoL), Venous Clinical Severity Score (VCSS), pain scores and time taken to return to normal function. Owing to the nature of the procedures, blinding was not possible. Both groups had significant improvements in VCSS after treatment (P < 0.001), which resulted in improved disease-specific QoL (Aberdeen Varicose Vein Questionnaire, P < 0.001) and quality-adjusted life year (QALY) gain (P < 0.001). The pain and disability following surgery impaired normal function, with a significant decline in five of eight Short Form 36 (SF-36(®)) domains (P < 0.001 to P = 0.029). Periprocedural QoL was relatively preserved following EVLA, leading to a significant difference between the two treatments in pain scores (P < 0.001), six of eight SF-36(®) domains (P = 0.004 to P = 0.049) and QALYs (P = 0.003). As a result, surgical patients took longer to return to work and normal activity (14 versus 4 days; P < 0.001). Complications were rare. EVLA was as effective as surgery for varicose veins, but had a less negative impact on early postintervention QoL. NCT00759434 (http://www.clinicaltrials.gov).

Standard guidelines for care: Sclerotherapy in dermatology

Sclerotherapy is defined as the targeted elimination of small vessels, varicose veins and vascular anomalies by the injection of a sclerosant. The aim of sclerotherapy is to damage the vessel wall and transform it into a fibrous cord that cannot be recanalized. It is a simple, cost-effective, efficacious and esthetically acceptable modality for both therapeutic and esthetic purposes. Therapeutic indications include varicose veins and vascular malformations. Esthetic indications include telangiectasias and reticular veins. In the management of varicose veins, it may need to be combined with other surgical methods of treatment, such as ligation of the saphenofemoral junction, stab ligation of perforators and stripping. A surgical opinion may be necessary. A thorough knowledge of the anatomy and physiology of the venous system of the legs, basic principles of venous insufficiency, methods of diagnosis and, in addition, uses, mechanisms of action and complications of sclerosing agents and proper compression techniques are important pre-requisites to successful sclerotherapy. Although various sclerosing agents are available, polidoconal and sodium tetradecyl sulfate are most commonly used. More recently, these sclerosants have been used in microfoam form for increased efficacy. The basic principle of a successful sclerotherapy technique is the use of an optimal volume and concentration of the sclerosant according to the size of the vessel. The sclerosant is injected carefully into the vessel and compression is applied. Contraindications include superficial and deep venous thrombosis, sapheno-femoral junction incompetence, pregnancy, myocardial decompensation, migraine, hypercoagulable state, serious systemic illness, dependency edema, immobility, arterial disease, diabetes mellitus and allergic reactions to sclerosants. While sclerotherapy is usually a safe procedure, complications may occur due to inappropriate patient selection or improper injection techniques. The complications may be acute or delayed. Complications include hyperpigmentation, matting, local urticaria, cutaneous necrosis, microthrombi, accidental intra-arterial injection, phlebitis, deep vein thrombosis, thromboembolism, scintillating scotomas, nerve damage and allergic reactions. Sclerotherapy may be administered by a surgeon or dermatologist who has acquired adequate training during post-graduation or through recognized fellowships and workshops dedicated to sclerotherapy. He should have an adequate knowledge of the anatomy of the venous system, be able to diagnose and manage venous disease and its associated consequences as well as possess the necessary skills to perform the procedures, understand the appropriate indications and limitations, technique modifications and management of the potential adverse sequelae associated with sclerotherapy and also understand the pharmacology of the sclerosing solutions. The procedure may be performed in the physician's procedure room.

Gastro-oesophageal reflux in noncystic fibrosis bronchiectasis.

The clinical presentation of noncystic fibrosis bronchiectasis may be complicated by concomitant conditions, including gastro-oesophageal reflux (GOR). Increased acidic GOR is principally caused by gastro-oesophageal junction incompetence and may arise from lower oesophageal sphincter hypotension, including transient relaxations, hiatus hernia, and oesophageal dysmotility. Specific pathophysiological features which are characteristic of respiratory diseases including coughing may further increase the risk of GOR in bronchiectasis. Reflux may impact on lung disease severity by two mechanisms, reflex bronchoconstriction and pulmonary microaspiration. Symptomatic and clinically silent reflux has been detected in bronchiectasis, with the prevalence of 26 to 75%. The cause and effect relationship has not been established, but preliminary reports suggest that GOR may influence the severity of bronchiectasis. Further studies examining the implications of GOR in this condition, including its effect across the disease spectrum using a combination of diagnostic tools, will clarify the clinical significance of this comorbidity.

Management Of Saphenofemoral Junction (SFJ) Incompetence In Varicose Veins: Simple High Ligation Or Stripping - A Prospective Randomized Study.

Varicose veins affect a significant percentage of population in the society. They may not cause mortality but are a cause of considerable morbidity if not properly treated. The present study was conducted on 100 patients of varicose veins admitted for surgery at Pt. B.D.Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak. The cases were randomly divided in two groups: Group A and Group B (simple high ligation or stripping) alternately. The maximum number of patients (64) was between 16-35 years of age. The most common complaint was dilated and tortuous vein (90%), followed by pain in leg (78%), edema (60%), ulcer and pigmentation (26%). Ulcer healing was quicker and ankle swelling subsided quickly in group B where above knee long saphenous vein stripping was done. There was no haematoma and paraesthesia in any group postoperatively. Redness and ecchymosis were observed in 6 patients (24%) with above-knee long saphenous vein stripping , decreased at 3 weeks and completely disappeared at 3 months. On colour Doppler examination, saphenofemoral reflux was observed in one patient with high ligation of saphenofemoral junction after six months, whereas in the above-knee stripping group no reflux was observed. The cosmetic results were equally good in both groups of the patients. Hence it was concluded that stripping of the long saphenous vein from groin to knee does not lead to any complication but symptomatic relief is early and better in the stripping group and there are less chances of recurrence.

Endovenous Laser Therapy in the Treatment of Lower-limb Venous Ulcers

To assess the efficacy of endovenous laser therapy (EVLT) in the treatment of lower-limb venous ulcers secondary to venous reflux. Forty-four of 139 patients referred for EVLT from January 2004 to August 2007 had nonhealing venous ulcers. Preprocedural duplex ultrasound (US) was performed to document saphenous venous reflux secondary to saphenofemoral/saphenopopliteal junction incompetence, deep venous insufficiency, and deep vein thrombosis. Follow-up intervals were within 1 week, monthly until ulcer healing, and every 6 months thereafter. Mean follow-up period was 35.8 months (range, 8.1-59.3 months). Mean great saphenous vein (GSV) diameter and length treated were 9.9 mm (range, 5.5-16.0 mm) and 36.7 cm (range, 20.0-60.0 cm). Mean laser energy used was 3,292 J (range, 1,392-4,971 J). Mean energy deposited per centimeter of vein was 93.6 J/cm (range, 45.2-182.0 J/cm). Mean laser time was 232 seconds (range, 99-347 sec). Fifteen patients with follow-up duplex US had no GSV flow at 6 months, with nonvisualization indicating complete obliteration. Ulcer healing occurred as early as 1 week after the procedure in some patients. Cumulative healing rates at 1, 3, 6, and 12 months were 82.1%, 92.5%, 92.5%, and 97.4%, respectively. No ulcer had recurred at 1 year, but ulcers recurred in five patients at 14, 14, 23, 35, and 52 months after EVLT, respectively. One patient with a nonhealing ulcer 2 years after treatment developed well differentiated squamous cell carcinoma. Ulcer epithelization occurred with continued GSV occlusion and loss of flow. Most ulcers healed within 3 months with no recurrence at 1 year. Nonhealing ulcers should undergo biopsy to exclude malignant transformation.

551 Effect of Gastric Emptying on Pressure-Flow Dynamics of Oesophago-Gastric Junction

Introduction Oesophago-gastric junction (OGJ) incompetence is a primary determinant of gastrooesophageal reflux disease (GORD) severity. Especially, the pressure-flow gradients across the OGJ during lower oesophageal sphincter (LOS) relaxation have important implications in GORD pathogenesis and subsequent planning of its treatment. Our aim was to evaluate the pressure-flow dynamic changes occurring at GOJ barrier during transient lower oesophageal sphincter relaxation (TLOSRs) and study the impact of gastric emptying after a meal on those events using combined high-resolution manometery and high-resolution impedance monitoring (HRMZ, ManoScan Z™). Methods HRMZ was performed in eight healthy subjects (6M and 2F, 27±7 years) for 4 h after a refluxogenic meal (1000 kcal). Pressure–flow dynamics of OGJ during TLOSR events including their frequency, duration, gastro-oesophageal pressure gradient (GO pressure gradient) and proximal extent of migration of the reflux episodes were computed. Gastric emptying of the meal was assessed by 13C-labelled octanoic acid breath test and gastric emptying lag time, half emptying time and gastric retention time were calculated. Results All subjects completed the study. During TLOSR events there was reciprocal relationship between GE pressure grad. and retrograde flow of gastric contents, the gradient was greatest at the onset of retrograde flow, decreasing progressively as the flow continued and became lowest by the end of flow across the OGJ (GO pressure gradient start of flow=9.5±2.6, peak flow=6.05±2.5 (p= Conclusion Our results suggest HRMZ is effective in elucidating the pressure-flow dynamics of OGJ. The proximal extent of the reflux episode correlates with gastric retention time of the meal; however other gastric emptying parameters did not show significant correlation despite promising trends. Further studies involving GORD patients might give us important insights into the role of OGJ pressure flow dynamics in the pathophysiology of GORD.

PWE-080 Effect of gastric emptying on pressure-flow dynamics of oesophago-gastric junction

<h3>Introduction</h3> Oesophago-gastric junction (OGJ) incompetence is a primary determinant of gastrooesophageal reflux disease (GORD) severity. Especially, the pressure-flow gradients across the OGJ during lower oesophageal sphincter (LOS) relaxation have important implications in GORD pathogenesis and subsequent planning of its treatment. Our aim was to evaluate the pressure-flow dynamic changes occurring at GOJ barrier during transient lower oesophageal sphincter relaxation (TLOSRs) and study the impact of gastric emptying after a meal on those events using combined high-resolution manometery and high-resolution impedance monitoring (HRMZ, ManoScan Z™). <h3>Methods</h3> HRMZ was performed in eight healthy subjects (6M and 2F, 27±7 years) for 4 h after a refluxogenic meal (1000 kcal). Pressure–flow dynamics of OGJ during TLOSR events including their frequency, duration, gastro-oesophageal pressure gradient (GO pressure gradient) and proximal extent of migration of the reflux episodes were computed. Gastric emptying of the meal was assessed by 13C-labelled octanoic acid breath test and gastric emptying lag time, half emptying time and gastric retention time were calculated. <h3>Results</h3> All subjects completed the study. During TLOSR events there was reciprocal relationship between GE pressure grad. and retrograde flow of gastric contents, the gradient was greatest at the onset of retrograde flow, decreasing progressively as the flow continued and became lowest by the end of flow across the OGJ (GO pressure gradient start of flow=9.5±2.6, peak flow=6.05±2.5 (p=&lt;0.05), end of flow=2.3±2.5 (p=&lt;0.001). GE pressure gradient was significantly higher for TLOSRs accompanied by significant retrograde flow (obvious flow on HRMZ display) compared with episodes with limited flow (&lt;3 impedance channels) (12.90±1.101 vs 6.858±1.388, p=0.01). TLOSR episodes accompanied by significant flow reached the upper oesophagus much more frequently than those episodes with limited flow (mean height of reflux episodes=13.46±3.4 vs 5.16±1.3, p=0.001). Significant correlation between height of reflux episodes and gastric retention time (r=0.7, p=0.04) week correlation trends were observed with gastric emptying lag time (r=0.4) and half emptying times (r=0.3). <h3>Conclusion</h3> Our results suggest HRMZ is effective in elucidating the pressure-flow dynamics of OGJ. The proximal extent of the reflux episode correlates with gastric retention time of the meal; however other gastric emptying parameters did not show significant correlation despite promising trends. Further studies involving GORD patients might give us important insights into the role of OGJ pressure flow dynamics in the pathophysiology of GORD.

980‐nm laser therapy versus varicose vein surgery in racially diverse Penang, Malaysia

Chronic venous disorders are conditions of increasing prevalence in the developing world, and venous ulceration is the terminal sequel. Currently there are only limited data on all aspects of this from Southeast Asia. The aim of the present study was to assess differences in the demography and outcome between varicose vein surgery (VVS) and the relatively new endovenous laser therapy (EVT) in patients from Penang, Malaysia. A retrospective study was performed. Patients who presented to the outpatient clinic of the surgical department with saphenofemoral junction and/or saphenopopliteal junction incompetence associated with reflux of the great saphenous vein or small saphenous vein, respectively, underwent either surgery (1999-2004) or laser therapy (2004-2006). A single surgeon at a single institution performed all procedures. A total of 350 limbs were treated from 292 patients. Demographics, symptoms, outcomes and complications that arose in both groups were compared. There were significant improvements in pains, swelling, cramps and heaviness postoperatively (P < 0.001) in both groups. Deep venous thrombosis was present as a complication in the VVS group at 3.0%, but was absent altogether in the EVT group. Although both are highly effective procedures, laser therapy has become popular as an elective procedure with its minimally invasive nature, cosmesis, rapid recovery and other advantages. Surgery remains an important and very cost-effective procedure, especially in a developing society such as Penang.

Endovenous Laser Ablation and Sclerotherapy for Treatment of Varicose Veins

Superficial venous insufficiency is a common problem associated with varicose veins. Venous insufficiency and varicose veins can be symptomatic, but more commonly they are a cosmetic concern. In this article, we discuss the relevant anatomy and pathophysiology of superficial venous insufficiency, review the current literature for varicose vein treatment, and cover the technical aspects of diagnosing and treating superficial venous insufficiency. Saphenofemoral junction incompetence with resultant greater saphenous vein reflux is the most common cause of varicose veins; because this condition constitutes the majority of patients encountered in practice, we will concentrate on this area. Endovenous laser ablation and sclerotherapy are covered, including patient workup and selection, procedure set-up, and anesthesia.

Randomised Trial of Flush Saphenofemoral Ligation for Primary Great Saphenous Varicose Veins

Objectives: The aim of this study was to assess different techniques of saphenofemoral ligation in the treatment of primary varicose veins. Methods: One hundred and eighty-two patients (210 legs) with primary saphenofemoral junction incompetence were randomised to standard saphenofemoral ligation (transfixion with an absorbable suture) (SSL) or flush saphenofemoral ligation (oversewing with 4/0 polypropylene) (FSL). All legs underwent additional great saphenous vein stripping and multiple phlebectomies. Patients underwent assessment preoperatively, and at 6 weeks, 1 year and 2 years postoperatively with clinical examination, duplex imaging and completion of the Aberdeen Varicose Vein Symptom Severity Score (AVVSSS). Results: A total of 148 patients (172 legs) attended follow-up at 2 years postoperatively. Recurrent varicose veins were visible in 30 legs (33 per cent) in the SSL group and 26 legs (32 per cent) in the FSL group (P = 0.90). Neovascularisation was present in 20 groins (22 per cent) in the SSL group and 15 groins (19 per cent) in the FSL group (P = 0.57). Nine cases of neovascularisation in the SSL group and five in the FSL group directly resulted in clinical recurrence (P = 0.37). Conclusions: Flush ligation of the saphenofemoral junction confers no advantage over standard ligation with respect to clinical recurrence and neovascularisation. Registration number: ISRCTN20235689 (http://www.controlled-trials.com).

Randomised Trial of Flush Saphenofemoral Ligation for Primary Great Saphenous Varicose Veins

ObjectivesThe aim of this study was to assess different techniques of saphenofemoral ligation in the treatment of primary varicose veins. MethodsOne hundred and eighty-two patients (210 legs) with primary saphenofemoral junction incompetence were randomised to standard saphenofemoral ligation (transfixion with an absorbable suture) (SSL) or flush saphenofemoral ligation (oversewing with 4/0 polypropylene) (FSL). All legs underwent additional great saphenous vein stripping and multiple phlebectomies. Patients underwent assessment preoperatively, and at 6 weeks, 1 year and 2 years postoperatively with clinical examination, duplex imaging and completion of the Aberdeen Varicose Vein Symptom Severity Score (AVVSSS). ResultsA total of 148 patients (172 legs) attended follow-up at 2 years postoperatively. Recurrent varicose veins were visible in 30 legs (33 per cent) in the SSL group and 26 legs (32 per cent) in the FSL group (P=0.90). Neovascularisation was present in 20 groins (22 per cent) in the SSL group and 15 groins (19 per cent) in the FSL group (P=0.57). Nine cases of neovascularisation in the SSL group and five in the FSL group directly resulted in clinical recurrence (P=0.37). ConclusionsFlush ligation of the saphenofemoral junction confers no advantage over standard ligation with respect to clinical recurrence and neovascularisation.Registration number: ISRCTN20235689 (http://www.controlled-trials.com).

Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength

Endosaphenous laser ablation is used in the treatment of great saphenous vein insufficiency with various methods, with and without surgical interruption. However, its mode of action and indications are not yet clear. To verify the mode of action of endosaphenous laser ablation by duplex ultrasound (DUS) follow-up, with the support of histologic observations of eight cases, 44 of 182 affected limbs (CEAP C2 to C6) were selected for intravenous laser ablation of the great saphenous vein. Saphenofemoral junction incompetence was treated by surgical interruption. An 808-nm diode laser (Eufoton, Trieste, Italy) was used (variable pull-back velocity, 1 to 3 mm/s; power, 12 to 15 W; energy, 30 to 40 J/cm). In eight limbs the venous fragments were studied under light microscopy at 5 minutes and after 1 and 2 months. In 44 limbs DUS and clinical examinations were performed from 7 days to 1, 2, 6, and 12 months. Variously organized thrombi containing necrotic inclusions and patent areas were observed in the vein lumen. Neither neovascularization nor thrombus extension were detected at the groin by DUS examination. Progressive venous diameter decrease and thrombus fibrotic transformation up to the hypotrophic venous disappearance at 12 months were followed up (P < .00001). Not occluded (18.8%), recanalized short segments (22.7%), two entirely recanalized saphenous veins with varicose recurrence (4.5%), and postoperative phlebitis (13.6%) were observed. Nonocclusions and phlebitis prevailed in the larger veins (P < .05). The healing process is based on vein thrombosis, fibrosis, and venous atrophy. Saphenofemoral interruption makes venous occlusion easier and prevents potential thrombotic complications and recurrence by recanalization. DUS monitoring makes possible to follow-up the thrombus involution and perform early retreatment. The 808-nm endosaphenous laser should be mainly applied to veins of <10 mm in diameter.